Medical Release Form And printable pdf download

Medical Release Form And

MEDICAL RELEASE FORM AND

RECEIPT OF NOTICE OF PRIVACY PRACTICES

LEBANON DERMATOLOGY CENTER

OFFICE OF:

CHARLES A. MITCHELL, MD

C. AUSTIN MITCHELL, MD

BARBARA E. WOLFF, PAC

LESA STOVALL, CPE

GINA SCOTT, PERMANENT COSMETIC SPECIALIST

DUE TO NEW LAWS REGARDING THE “PATIENT PRIVACY ACT” WE NEED PERMISSION

(IN WRITING) FROM YOU TO ALLOW ANY REPRESENTATIVE FROM OUR OFFICE TO SPEAK TO A

FAMILY MEMBER AND/OR LEAVE MESSAGES ON ANSWERING MACHINES/VOICE MAIL

REGARDING YOUR CARE AND TREATMENT.

* WHAT IS THE BEST NUMBER OR NUMBERS TO REACH YOU?

__________________________________________________________________________________________

* WHAT IS THE BEST TIME TO CALL?

MORNING

AFTERNOON

ANYTIME

PLEASE CHECK THE BOX OR BOXES THAT APPLY:

_____ THE STAFF OF LDC MAY SPEAK ONLY TO THE PATIENT REGARDING ANY

AND ALL MEDICAL INFORMATION.

_____ THE STAFF OF LDC MAY LEAVE A DETAILED MESSAGE ON ANSWERING

MACHINES/VOICE MAIL.

_____ THE STAFF OF LDC MAY SPEAK WITH THE PERSON OR PERSONS LISTED:

(

PLEASE GIVE NAME AND RELATIONSHIP TO PATIENT)

________________________________________________________________________

_____ THE STAFF OF LDC MAY MAIL INFORMATION TO MY HOME.

THE DRUG STORE I CURRENTLY USE IS:

(NAME, CITY, AND PHONE NUMBER IF KNOWN)

___________________________________________________________________

I AM AWARE OF AND HAVE BEEN OFFERED A COPY OF THE LEBANON DERMATOLOGY

CENTER NOTICE OF PRIVACY PRACTICES.

_______________________________________________________

______________________________

SIGNATURE OF PATIENT OR LEGAL GUARDIAN

DATE

_______________________________________________________

RELATIONSHIP IF OTHER THAN PATIENT

Medical Release Form And